Complaints policy for the Coroners Court



The Office of the Chief Coroner (OCC) and Coronial Services (CS) Complaints Policy details the policy, guiding principles and business processes involved in resolving complaints.


References to ‘the Act’ or legislative provisions refer to the Coroners Act 2006. Any other Act is mentioned in full.

In this chapter

This chapter contains the following topics:

Roles and responsibilities


The table below outlines the responsibilities of the different roles in the complaints process.

Chief Coroner Is kept informed of all complaints that involve a Coroner. Resolve the complaint.
Judicial Support Manager Is kept informed of all complaints that involve a Coroner. Manage the complaints process. Maintains the OCC register of complaints.
Operations Manager Is kept informed of all complaints that involve CSU staff and takes ownership of complaints regarding CSU staff and administrative/systemic issues. Maintains the Coronial Services register of complaints. Meets with staff member about whom a complaint is received.
Regional Manager Follows up on complaints as directed by Operations Manager.
Business Services Administration of complaints. Has oversight of Operations Complaint Register and receipt acknowledgement and distribution of complaints, including Ministerial complaints.

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Complaints guiding principles


The process maps below(external link) describe the order of events and who is responsible. It covers complaints raised via:

  • Coronial Services website
  • CS information email (
  • CS regional offices
  • Office of the Chief Coroner (OCC)
  • CS Operations Manager
  • Coroners
  • National Initial Investigation Office (NIIO)

Coronial Services undertakes to conduct these processes in accordance with the principles of natural justice (fairness, transparency, and consistency). This necessitates the person to whom the complaint refers being informed of the complaint.

Sometimes a complaint is found to involve persons who are not Coroners or Coronial Services staff. The Chief Coroner and/or CS Operations Manager will make a decision as to whether to refer this on to the person involved or require the complainant to approach that person directly.

Complaint sources

Complaints about a Coroner or Coronial Services staff, processes or systems, arise from a number of sources, including the following:

  • Families of deceased
  • People or organisations that have been the subject of comments or recommendations made as a result of a Coroner's inquiry
  • Observations or complaints raised by Ministry staff (‘Ministry concerns’)
  • Members of Parliament
  • Other interested parties such as Medical Professionals, Police, Funeral Directors or District Health Boards.

Complaint format

This process only covers written complaints referred to the CSU. If a complaint is received verbally, the complainant will be asked to put their complaint in writing in order for it to be addressed.

If a complainant raises a complaint directly with the Chief Coroner, the Chief Coroner will in the first instance attempt to resolve the complaint, and this process will be managed by the Judicial Support Manager.

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Complaints register

The OCC and CS records all written complaints in the relevant Complaints Register. The Judicial Support Manager is responsible for maintaining the register in respect of complaints involving Coroners and the Operations Manager for complaints involving staff, processes or systems.

The register records:

  • the source of the complaint
  • name of deceased
  • area or district
  • name of complainant
  • date complaint received
  • who received the complaint
  • summary of complaint
  • other notes
  • Investigator
  • due date
  • response to the complaint / outcome of the complaint and whether or not it has been substantiated
  • acknowledgement / date / by who
  • CS file number

Complaints management timeframes

The CS timeframes for managing complaints are shown in the table below.

Number of working days from receipt of complaintAction(s) taken
Within 5 working days Acknowledged receipt of the complaint to the complainant
Within 20 working days Provided a response to the complainant


The OCC and CS will comply with an internal audit of the complaints process by the Ministry on request.

Audits of complaints about coroners are not appropriate as coroners are independent judicial officers and complaints of a judicial nature are dealt with by the Judicial Conduct Commissioner and Chief Coroner, not Coronial Services.


The OCC/CS will provide data for internal and external reports.

This will include:

  • numbers of complaints received
  • numbers of complaints substantiated
  • nature of complaints

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Managing the complaints process


This topic sets out the principles that guide the management of the OCC/CS complaints process.

Natural justice

The OCC and the CS undertakes to conduct its process in accordance with the principles of natural justice (fairness, transparency and consistency). In the case of complaints against a Coroner, the process will be consistent with the independence of the judiciary and the role of the Chief Coroner and the Judicial Conduct Commissioner.

Efficient, effective, impartial and fair

The complaints process:

  • is timely
  • thoroughly investigates all relevant matters
  • is transparent
  • is fair
  • is confidential (including considerations of privacy)
  • is free from:
  1. bias
  2. external influence
  3. conflicts of interest, or
  4. impropriety

Note: Fairness includes:

  • ensuring that all parties to a complaint know what to expect during the complaints process
  • providing reasons for decisions
  • ensuring that all participants in the process are given a reasonable opportunity to respond.

Open, accessible and accountable

The complaints process:

  • is easily accessible to potential complainants
  • provides clear and simple guidance on complainants’ rights
  • is open and accountable, and
  • allows participants and the public to provide feedback about the effectiveness and fairness of the process

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Investigating a complaint

Judicial Conduct Commissioner

Where the OCC receives a complaint regarding a Coroner, the OCC will forward contact details of the JCC to the complainant.


Before commencing an investigation into the complaint, the OCC/CS:

  • determines whether the complaint is related to a Coroner or to a CS staff member or both, and/or related to administrative or systemic issues
  • assesses the severity of the complaint and assigns accountability for investigation (see Types of Complaints).


CS Operations Manager or delegate arranges a meeting with the relevant staff member to advise them of the complaint and will ask for information from that staff member.

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Responding to a complaint

OCC – Chief Coroner responds

Following investigation of a complaint made regarding a Coroner, which does not need to be referred to the JCC, the Chief Coroner will respond to the complaint.

CSU Operations Manager responds

Following investigation of a complaint made regarding a CS staff member, or about administrative and/or systemic issues, the CS Operations Manager at his/her discretion will communicate with the appropriate Regional Manager, Judicial Support Manager or NIIO Manager to respond to the complaint accordingly.

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Flow chart - Acknowledging and investigating

Flow chart: Acknowledging and investigating complaints
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Flow chart - Responding

Flowchart: Responding to complaints
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Types of complaints



This topic outlines how complaints will be dealt with by Coronial Services and the Office of the Chief Coroner.

Complaints will be categorised as minor, serious or very serious, dependent on:

  1. the context and the potential impact both internally and/or externally
  2. giving consideration to compliance with the Ministry of Justice Code of Conduct and other relevant policies
  3. compliance with Coronial Services Standard Operating Procedures

The following is a list of complaint examples that may be received. The list is not exhaustive and is not ranked in any defined order.

  • Incorrect sending of information that includes personal information
  • Failure to send inquest and chambers notifications
  • Disclosure of information to incorrect parties
  • Failure to comply with the Ministry of Justice Code of Conduct and other relevant policies
  • Failure to comply with Standard Operating Procedures
  • Providing incorrect verbal or written advice to a family / staff member / stakeholder or agency
  • Failure to enter data correctly
  • Errors and mistakes
  • Failure to carry out the role of Court Registrar competently (includes failure to use/engage an interpreter)
  • Failure to carry out the role of Counsel to Assist competently
  • Delay with coronial inquiry
  • Errors or mistakes in Coroners’ findings

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Appendix - Glossary of terms


Any expression of dissatisfaction with services provided. This includes all complaints regardless of their origin. See Types of Complaints for specific examples of complaints that may fall within minor, serious or very serious categories.

Complaints Register

Internal monitoring and reporting tool where complaints are recorded. Separate complaints registers are held for the Office of the Chief Coroner and Coronial Services.

CS Staff

A person employed by the Ministry of Justice, Coronial Services Unit under an employment agreement.


Office of the Chief Coroner - The Chief Coroner

Internal Audit

Independent, objective assurance and consulting activity designed to add value and improve an organisation's operations.

Open and accountable

Provide clear guidance about the criteria that is used for deciding remedies. When offering a remedy, we shall explain to the complainant how a decision was reached and a clear record of the decision and the reasons for it noted on the register.

Natural Justice

Natural justice comprises two rules, the rule against bias and the rule of the right to a fair hearing. Because of the necessity of maintaining public confidence in the legal system - which includes not only the courts but all public decision making bodies, it is most important that people who are engaged in these processes feel that they have had a fair hearing and that there has been no bias.

Procedural fairness to ensure a fair decision is reached by an objective decision maker.

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